Tip: Know when to report secondary diagnoses

CDI Strategies, March 17, 2011

A patient’s medical record could include a laundry list of diagnoses, but not all of these conditions may be reportable. Coders must determine when they can report conditions as “other” secondary diagnoses and when they must simply leave them off the claim entirely.

It also could leave a hospital vulnerable to a RAC audit, particularly when the diagnoses in question are CCs or MCCs that yield a higher-weighted DRG. However, underreporting secondary diagnoses can also be detrimental in terms of quality and reimbursement, so hospitals must find a compliant balance between the two, says Bryant.

CDI specialists can help address cases in which the documentation is unclear. Unclear documentation is an unfortunate reality that many coders face when physicians suspect a condition, document it initially, rule it out mentally (but fail to provide documentation), and then simply stop documenting the condition entirely in the record.

The Uniform Hospital Discharge Data Set defines “other diagnoses” as:

“All conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be excluded.”

For reporting purposes, the ICD-9-CM Official Guidelines for Coding and Reporting define “other diagnoses” as additional conditions that affect patient care because they require one or more of the following:

Clinical evaluation

Therapeutic treatment

Diagnostic procedures

Extended length of hospital stay

Increased nursing care and/or monitoring

Consider the following questions before reporting secondary diagnoses:

Does documentation support assignment of the diagnosis in accordance with the reporting guidelines? If documentation supports assignment, is the diagnosis eligible for reporting as a secondary diagnosis (i.e., does it meet reporting criteria)?

Does documentation include clinical indicators that justify a query for a more specified or definitive diagnosis?

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